Early Lessons from the Work Support
Strategies Initiative: North Carolina
Pamela Loprest and Lindsay Giesen
March 2013
Acknowledgments
The Ford Foundation has provided generous lead funding for the Work Support Strategies
(WSS) project, committing more than $20 million in total. The Special Fund for Poverty
Alleviation of the Open Society Foundations, the Kresge Foundation, and the Annie E. Casey
Foundation also gave crucial support. The authors would like to thank Olivia Golden, Stacy
Dean, Dottie Rosenbaum, Gina Adams, and North Carolina’s WSS team for their review of
earlier drafts and for the many comments and insights provided. The authors would also like to
express gratitude to the many staff members in North Carolina who participated in the site visit
interviews; to Serena Lei, Fiona Blackshaw, and Scott Forrey of the Urban Institute’s
communications team for their extraordinary editorial assistance; and to members of the national
WSS team, including Michael Tutu, for their assistance. The views expressed in this publication
are those of the authors and do not necessarily reflect those of the Urban Institute, its trustees, or
its funders.
Contents
North Carolina’s Goals for the Planning Year
2
State Background
2
Gaining Traction for Change through Vision and Leadership
4
Aligning Technology with Policy, Process, and Vision
7
Changing Governance to Promote Cross-Program Solutions
9
Moving Forward as a State-County Team
12
Using Data to Shape Policy, Process, and Technology Decisions
16
Using the Planning Year to Build Momentum and a Culture of Learning
18
Conclusions
22
References
24
Methodological Note
25
North Carolina, one of the fastest-growing states in the
country with a large low-income population, was hit hard
by the Great Recession. Caseloads for work support
programs expanded rapidly, and the inefficiencies of the
old human services system—with different eligibility
processes for each program—began to seem untenable. At
the same time, a long-term effort to create a modern,
integrated computerized benefit system was finally moving
toward implementation, offering an opportunity for change.
North Carolina is one of about 10 states where public
programs are overseen by the state but administered at the
county level. In North Carolina, this means that each of the
100 counties operates the programs in its own way, while
the state agencies issue policy and regulations. The state
policy processes for Medicaid, SNAP, and child care
subsidies were entirely separate even though they were
housed in the same department. Also, counties generally
administered the three programs separately, using different
workers and different eligibility processes for each
program. Clients often must duplicate their paperwork and
visit multiple offices, making it difficult and confusing to
obtain and keep benefits.
In 2011, North Carolina won a Work Support Strategies
(WSS) grant to help streamline the system for connecting
low-income families to work support benefits. This
multiyear initiative, funded by private philanthropy, gave
grants to select states to test and implement more effective
and integrated approaches to delivering key work supports,
including health coverage, nutrition benefits, and child care
Work Support Strategies
Work Support Strategies (WSS) is a
multiyear initiative to simplify the process
of getting work support benefits. Working
directly with selected states, WSS seeks to
improve the health and well-being of
low-income families by increasing
enrollment in work support programs;
deliver benefits more effectively and
efficiently, reducing administrative
burdens on states as well as clients; and
evaluate the impact of these
streamlined approaches, disseminate
lessons learned, and inform state and
federal policies.
WSS focuses on three work support
programs: the Supplemental Nutrition
Assistance Program (SNAP), Medicaid and
the Children’s Health Insurance Program
(CHIP), and child care subsidies through the
Child Care and Development Block Grant.
Participating states may choose to add
other programs, and most have done so.
In fall 2010, WSS invited states to apply for
one-year planning grants, with the
opportunity to continue to a three-year
implementation phase. Twenty-seven states
submitted applications, and nine were
competitively selected: Colorado, Idaho,
Illinois, Kentucky, New Mexico, North
Carolina, Oregon, Rhode Island, and South
Carolina. During the planning phase, the
selected states received $250,000, expert
technical assistance, and peer support from
other states. With these resources, the
grantees performed intensive diagnostic
self-assessments, explored business process
strategies, established leadership
structures, and developed data-driven
action plans that address policy and
practice changes.
This report is one of 10 (one on each state,
plus a cross-cutting report) describing state
activities during the planning year.
Early Lessons From The Work Support Strategies Initiative: North Carolina
1
subsidies. Streamlining and modernizing these processes can help improve the health and wellbeing of low-income families, save states money, and improve overall efficiency.
North Carolina’s Goals for the Planning Year
The North Carolina team’s goal for the planning year was to
design and lay the groundwork for a comprehensive, crosscutting service-delivery model. The state coordinated the efforts
of counties and state agencies to improve service delivery across
programs, reduce administrative burden, and increase client
access. A number of earlier initiatives had sought to make it
Work Support Programs
Included in North Carolina’s
Planning Year
FNS: Food and Nutrition Services (North
Carolina’s name for the Supplemental
Nutrition Assistance Program [SNAP])
easier for low-income families to access and keep the different
CHIP/Medicaid: Children’s Health
Insurance Plan and Medicaid
work support programs, but those piecemeal initiatives each
Child Care: Subsidized Child Care
addressed a single program, not the opportunities across
programs. The WSS team in North Carolina hypothesized that
tearing down program silos and streamlining services would
make better use of limited resources and better stabilize
LiHEAP: Low-Income Home Energy
Assistance Program
Work First: North Carolina’s name for
the Temporary Assistance for Needy
Families (TANF) program
vulnerable families.
State Background
In 2011–12, the WSS initiative’s planning year, North Carolina had a split-party government,
with a Democratic governor and a Republican legislature. Lanier Cansler was the cabinet
secretary for the Department of Health and Human Services, which housed all the state’s major
public health and human service benefit programs. Cansler, who had been both a Republican
legislator and the deputy secretary of the agency many years earlier under a Democratic
governor, was seen as a bipartisan figure. He was asked by the governor to run the department,
given his many years of focus on health and human services issues.
The WSS team in North Carolina in Phase I was led by Sherry Bradsher, director of the
Department of Social Services for more than 10 years. Joining her as key members of the team
were the Food and Nutrition Services (FNS) director (and WSS project manager), section chief
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Work Support Strategies
A Quick Glance at North Carolina
Population (in thousands): 9,535 (ranked the 10th-largest state)
a
Share of individuals living below 200% of the federal poverty level (FPL) (in 2011): 39.3%
b
Unemployment rate (in September 2012): 9.6%
Share of eligible people participating in SNAP (in 2010):c all individuals, 78%; working poor, 71%
d
Share of eligible children participating in Medicaid/CHIP (in 2010): 88.1%
State Medicaid upper-income eligibility limit as % of FPL:e children, 200%; working parents, 47%
Programs state or county administered? County
Number of counties: 100
Lead WSS agency: Department of Health and Human Services (DHHS)
SNAP governance: DHHS > Division of Social Services (DSS) > Food and Nutrition Services
Medicaid governance: DHHS > Division of Medical Assistance (DMA) > Medicaid
Child care governance: DHHS > Division of Child Development and Early Education (DCDEE) (overseer) > County
DSS office
NC FAST: North Carolina Families Accessing Services through Technology
Sources: a U.S. Census Bureau (2013); b Bureau of Labor Statistics (2012); c Cunnyngham (2012); d Kenney et al.
(2012); e Kaiser Family Foundation (2013).
of the subsidized child care program, chief of the Medicaid Eligibility Unit, and director of the
Catawba County Department of Social Services. An outside consultant with whom North
Carolina was working on other projects was included to carry out day-to-day project
management.
The report is organized into six key areas that were critical to North Carolina’s planning
year: setting and communicating the WSS vision, aligning technology with that vision,
promoting cross-program solutions, collaborating with counties, using data strategically, and
building momentum for change.
Early Lessons From The Work Support Strategies Initiative: North Carolina
3
Gaining Traction for Change through Vision and Leadership
“[The WSS team has] more of a vision now of what we want our processes to look like two
years out or three years out…..That’s why this project will stand the test of time.”
—Senior state WSS team leader
At the start of WSS, many projects to simplify policies and processes were already underway in
North Carolina, including NC FAST, a new integrated IT benefits system; the Integrated
Eligibility project, an ongoing effort to align policies and procedures for eligibility determination
across programs; and planning for health reform. In addition, when Cansler became cabinet
secretary, he began the DHHS Excels initiative, which was aimed at changing the state agency
culture to be more customer focused, anticipatory, transparent, collaborative, and outcomesfocused.
The WSS team faced an early challenge in synthesizing and communicating the vision
behind these initiatives; building appropriate connections between them; and garnering support
for change at legislative, state agency, and county levels. Early in the planning year, the team
articulated its vision in one clear and simple idea: “Families will tell their story once and receive
the services they need.” In other words, the vision was for a comprehensive, cross-cutting
service-delivery model with no wrong door: Any person in need of assistance would be able to
walk into a local office, speak with one worker, complete one application, and receive every
form of assistance for which they were deemed eligible. This vision is in marked contrast to the
system in place, which differed across counties but usually required applicants to interact with
workers for each program separately.
This “no wrong door” vision was a paradigm shift for human services delivery in North
Carolina. It required breaking down programmatic silos at both state agency and county office
levels, and redefining good customer service as that which ensures a client not having to visit
multiple offices or seeing a succession of caseworkers during the same visit. A more integrated,
efficient, and effective system—if successfully implemented—would reduce duplication of
effort, reduce error rates, save money, and stabilize vulnerable families by improving their wellbeing and ability to work. The WSS project was “at the right place at the right time,” WSS
leadership said, to be a vehicle to develop, promote, support, and expand this vision.
4
Work Support Strategies
A great deal of the direction and support for this vision came from Cansler, who had been
working for nearly a decade to realize better integrated and coordinated human services. Cansler
used his experience as a former legislator to help communicate this vision to a diverse group of
key partners, including the governor and legislators of both parties. He publicly supported the
WSS project and asked one of his deputies to travel around the state to educate different
divisions and departments on WSS and other concurrent initiatives. These efforts shaped the
WSS team’s early focus on a wide-ranging external strategy as well as internal improvements;
showed that Cansler was prioritizing WSS and its goals; and helped the team reach senior-level
department and political leaders.
Consistent with the secretary’s approach, the WSS team at all levels also actively reached out
to key partners. They met with legislators to make the business case for the project and worked
hard to gain the support of county program leaders and staff. Legislators of both parties
responded with letters of support. The team’s outreach extended and benefited from backing
from the governor’s office and cabinet secretaries. Support from those high-level officials gave
weight to the team’s vision for human services delivery, while the consistency of that message
from all levels communicated that momentum was building, up and down the chain of command.
As the WSS team members talked about the vision, they encountered concerns and pushback,
which they learned to address. For example, some members worried that the changes might be
temporary and would not endure beyond a single administration. State WSS team members
suggested that the strength of a big-picture vision is that it provides a holistic message for
customer service that can transcend administrations; it, thus, encourages change because counties
and programs feel that they have a framework that can take them into the future. In addition, as
more partners and stakeholders bought into the vision, DHHS program staff and county staff
increasingly came to feel that they could make changes without fear that those changes would be
rescinded later.
Another challenge was changing the culture of program segregation at the state level.
Although North Carolina’s key work support programs (Medicaid/CHIP, SNAP, child care, and
LiHEAP) were all housed within the same agency, they largely operated independently. Some
Early Lessons From The Work Support Strategies Initiative: North Carolina
5
programs performed well, but the performance of an individual program is only a piece of the
larger picture.
This idea of breaking down silos was not new to the state, but the strong vision and focus of
WSS helped push these efforts forward. According to one team member, after the planning year,
state programs and staff now “look at the person as a whole,” rather than as separate needs
served by separate programs. The WSS vision and the consistent message from many levels
changed staff’s perspective. “It’s hard to measure, but sometimes the biggest challenge… is
changing the conversation,” one key WSS team member said. “As the year progressed, I felt like
from bottom-up, top-down, we had changed the conversation.”
This change in perspective was also supported by the DHHS Excels initiative to make stateagency culture more customer focused. Over the course of the planning year, the WSS team
moved this culture change to a higher level: It went from a concept of what they were trying to
do in the department to what they were trying to do across the state.
Given the many different initiatives going on concurrently in North Carolina, the WSS team
was also an opportunity to figure out how to knit everything together. Fortunately, the strong
WSS vision served to unite concurrent projects, as WSS’s goals and vision were integrated over
time into the department’s structure and into the major initiatives—particularly health reform and
the automated eligibility system known as North Carolina Families Accessing Services through
Technology (NC FAST). Some initiatives were completely rolled into WSS (specifically, the
integrated eligibility policy initiative), while WSS served as a framework for integrated work on
NC FAST and health care reform. Creating ties between these initiatives and discussing the
future of human services as a whole led to the sharing of resources and personnel, enhancing the
state’s capacity to move toward the same set of goals. Additionally, establishing those links from
the beginning meant that the WSS team, the NC FAST team, and the health reform staff avoided
having to do a lot of work to match and merge efforts at the end because those conversations
were happening from the start.
6
Work Support Strategies
Aligning Technology with Policy, Process, and Vision
“If you just apply technology to bad processes, you just have a faster way of doing inefficient
things.”
—State staffer
For more than a decade, North Carolina has been developing and laying the groundwork for a
new computer system called North Carolina Families Accessing Services through Technology,
or “NC FAST” (see box for further details). In clear alignment with WSS goals, NC FAST is a
tool to speed up case processing through greater automation and less duplication of tasks, which
reduces the burden on workers and makes it easier for clients to access benefits. One member of
the NC FAST development team said, “The goal was [to] do a holistic approach. We’re looking
at the person coming in the door, and we don’t want them to get barraged with the same requests
for information. Everybody understood that the client comes first.”
The system, when fully implemented, would have tools to help determine eligibility for
multiple programs, online information verification, comprehensive case management functions,
an electronic preassessment screening tool, and interfaces between programs to promote
information sharing. NC FAST will also serve as the framework for North Carolina’s health
reform implementation.
What Is NC FAST?
Over the past decade, North Carolina has been developing an integrated eligibility system called North Carolina
Families Accessing Services through Technology, or NC FAST. As described on the state web site (listed below), NC
FAST “introduces new technological tools and business processes that will enable workers to spend less time on
administrative tasks and more time assisting families.” These tools include improved case management functions,
online verification of information, an electronic screen for services, and interfaces between programs to promote
information sharing.
The goals of NC FAST include automating tasks to help workers assess needs and determine eligibility, sharing data,
coordinating services, and making data accessible to track and evaluate outcomes and to ensure accountability.
Ten programs are included in the scope of NC FAST, and the system will house DHHS program data once contained
in nearly two dozen old mainframe systems. NC FAST will also serve as the portal to the state health exchange
under health reform.
While development has proceeded in fits and starts, given issues with funding and competing priorities, the past
two years have seen an intensive push to finish developing the system. Staff began rolling out NC FAST to counties
for SNAP eligibility processing in early 2012 and plan to finish the rollout of all 10 programs in 2017.
For more information: http://www.ncdhhs.gov/ncfast/program/program.htm
Early Lessons From The Work Support Strategies Initiative: North Carolina
7
The systems changes developing through NC FAST carry solutions to several big challenges
in North Carolina: merged databases that enable staff to look at data across programs and over
time, document-imaging capabilities, and improved case-management functions for counties.
State and county staff expressed excitement for the rollout of NC FAST, which they believe will
make programs more efficient and effective.
Systems like NC FAST can dictate how business is conducted, make new possibilities
available, and aid in carrying out policy or practice changes, but the North Carolina team found
that technology alone would not be enough to sustain lasting change. “We thought technology
would lead the way, originally,” a senior DHHS official told us. “But realized if we didn’t
change the culture locally to match state culture change,” little would change in practice. We’d
have centralized eligibility, but it wouldn’t mean a lot if you go into a local office and see three
people for three programs,” the official said. Achieving the “no wrong door” vision across the
state would take more than technology improvements alone: The team realized that a broad
cultural change needed to take place across the state at all levels.
County directors echoed the sentiment that technology can only be one part of the solution.
Even though counties primarily bear the weight of the recent rise in caseloads, county directors
did not see upgrading technology alone as the answer. Instead, they supported changing policies
and business practices alongside improving technology—even though doing so takes time and
requires thoughtful planning. “Policy changes are critical… simplifying business processes is
critical,” one county director said. “Technology can only implement some results….We can’t
expect it to solve everything.”
The WSS team members concluded that new technology should only support—not shape—
their vision, and it should be put in place along with necessary business process and policy
changes. To ensure that support, the WSS team worked with NC FAST staff to shape the tool to
fit the vision. Both teams shared members and participated in each other’s meetings to guarantee
everyone was working toward the same outcomes for workers and families. For example, a
number of DHHS staff members from FNS and Medicaid were detailed to work on the NC
FAST development team to help design the system rules. The NC FAST business manager was
part of the Integrated Eligibility project team, giving perspective on how policy changes could
8
Work Support Strategies
impact the automated system. Beginning this collaboration early paid off: State and county
staffers had a chance to communicate their needs before the NC FAST rollout, which increased
the tool’s usefulness and reduced the need to make changes after implementation. At the same
time, the WSS team was able to use NC FAST to help achieve the new vision for service
delivery in North Carolina.
Changing Governance to Promote Cross-Program Solutions
“You had to get everyone thinking about the best thing for the families and for counties
trying to administer all these programs. We were making the process hard—writing policies
separately.”
—WSS state team member
The Integrated Eligibility project, ongoing in North Carolina when WSS began, took steps to
eliminate inefficient or duplicative policies by cataloguing program requirements and searching
for ways to align them across programs (SNAP, Medicaid, and TANF were among the programs
included). The extensive policy reviews conducted under that project fed naturally into the work
undertaken by the WSS team; however, the work was painstaking and slow. For example, team
members identified numerous different definitions of income used across the programs, which
they were eventually able to condense into a much smaller group of income items.
Using information collected by the Integrated Eligibility project, WSS began putting crossprogram solutions into place. One of the first quick hits was using SNAP income information to
determine eligibility for child care. This coordination saved child care workers the time and
effort spent in gathering income information, freeing them up to talk with families about meeting
their child care needs. But this change required more than just a policy decision. Enthusiasm for
the change varied across counties. Some workers were hesitant at first and needed additional
training and assurances. Some wondered what would happen if the SNAP income determination
was wrong: Would errors reflect back on them? Through training and communication, the child
care workers learned of the robustness of SNAP income determinations and, for the most part,
came to trust and appreciate the change.
Early Lessons From The Work Support Strategies Initiative: North Carolina
9
Another cross-program policy issue identified early on as important was the alignment of
certification periods across programs to limit duplication of administrative tasks across
programs, decrease administrative churning, and reduce the complexity of accessing benefits for
clients. While Medicaid had previously aligned certification across its separate programs for
different members of the same household, doing so across all programs was a bigger task. The
state developed a special pilot project in two counties to explore this issue, with some success
(see box for details). This pilot highlighted a process for trying out policy changes generally,
including engaging county staff, revising processes, and collecting relevant data. WSS team
members pointed out that NC FAST technology would make it easier to share cross-program
information.
The WSS team members expected health reform to have a tremendous impact on work
support programs, compelling them to get a solid understanding of the state’s plans to comply
with the health reform legislation and to integrate their vision with these efforts. Because NC
FAST will serve as the connection to the state health exchange and will act as one of the main
Aligning Certification Periods
As part of WSS, North Carolina conducted a pilot in two counties to align certification periods for clients’ SNAP and
Medicaid benefits. Workers actively aligned certification periods when people applied for SNAP and realigned
certification dates for recertifying clients. After alignment, whenever clients recertified their SNAP benefits, they
were automatically recertified for Medicaid. The pilot project team included state division leaders, county leaders,
and frontline staff from the counties.
The pilot used SNAP as an “anchor” benefit for entry into the pilot, meaning the new policy was applied to people
signing up for or recertifying SNAP benefits. This structure was chosen because Medicaid clients do not need to
come into the office, and all but one element of Medicaid eligibility was already collected for SNAP eligibility. The
pilot started with walk-in clients and then expanded to clients using mail-in and drop-off applications and
recertifications.
Counties were able to choose how to integrate the new policy into their existing processes. The pilot project team
developed a “visioning” tool to help counties think creatively about how to put the policy into practice. The project
team also developed a data-tracking tool to collect data for use in evaluating the pilot’s effectiveness. The project
team worked intensively with the counties at first, holding weekly calls, and then scaled back to monthly calls.
The pilot demonstrated that most clients in the pilot counties (85 percent) did not have aligned recertification
periods before the pilot. Under this new policy, recertification dates in the two counties were aligned for about
half these clients. The most common reason for not carrying out alignment was a Medicaid recertification date
more than six months in the future or the denial of benefits.
More details can be found in Public Consulting Group. 2012. “North Carolina Department of Health and Human
Services Aligned Certification Periods Pilot Study Final Report.” The new alignment policy will be implemented
statewide.
10
Work Support Strategies
tools helping the WSS team achieve its vision for the reengineered delivery of human services,
these efforts needed to move in tandem. Staff leading preparations for health reform,
implementing WSS, and preparing for the rollout of NC FAST participated in each other’s
meetings. As one WSS team member said, they bring “ideas back and forth to create a more
comprehensive strategy.” Changes to policy or process under consideration by the health reform
team were discussed with the NC FAST and WSS teams to make sure everyone worked toward a
shared vision and didn’t obstruct the efforts being made in other areas.
Across these efforts to simplify policy and take action on detailed findings, the team
identified deep-seated institutional barriers that made good, integrated policy hard to enact. Two
of the main barriers were the practice of making policy change by program rather than across
services as a whole and the delays caused by how long it took to change state rules and policies.
WSS found ways to overcome both challenges during the planning year.
The cross-program Policy Governance Board (PGB) was established by the DHHS Secretary
during the planning year to tear down siloed program policy committees and restructure the
process to better coordinate and manage integrated policy development and eligibility
determination. The board serves as the central structure through which policy change
determinations are made across programs. All policies and procedure changes for DHHS are put
before the group for discussion and decisions. The PGB is comprised of state representatives
from DMA, DSS, DCDEE, Division of Aging and Adult Services, and NC FAST. The directive
establishing the PGB also states that it will directly interface with the North Carolina Association
of County Directors of Social Services (NCACDSS) and the WSS committee, which ensures that
both state and county voices are collaborating and coordinating their efforts. The board members
are not likely to turn over at each change of administration, which helps ensure continuity for
policy decisions.
The cabinet secretary signed an order establishing the board, which signaled senior-level
support for integrating and streamlining services. In addition, establishing the PGB served, as
one county director noted, as a tangible sign of real progress. It also served as a symbol of the
broad changes the WSS team sought to make: a collaborative, coordinated, and integrated system
that better serves vulnerable families.
Early Lessons From The Work Support Strategies Initiative: North Carolina
11
Moving Forward as a State-County Team
“This initiative [WSS] has created more communication and dialogue than what I’d
experienced in the [past] two years.…As a result of WSS, I personally have a closer
relationship and am able to more readily get information from the [state] division chiefs
than…in the past.”
—WSS county representative
North Carolina is county administered and state supervised, which means that the state sets
policy, but each of the 100 counties has a great deal of flexibility in how to implement those
policies. County Department of Social Services (DSS) offices are part of local government, but
the county DSS offices also act as agents of the state under the authorization and supervision of
the State DSS in the state’s DHHS. Each county is responsible for eligibility determination,
enrollment, and retention for work support and public benefits programs. In some counties, child
care subsidy eligibility is subcontracted out to nongovernmental organizations. Every county
runs differently.
For state staff trying to move toward a more streamlined and integrated model, this system
posed challenges. State officials believed that changes in county processes were necessary to
make the most of the coming integrated technology and to improve outcomes for clients. The
challenge is how to achieve change statewide among 100 independently administered counties
when the state has little direct authority over county processes. The state DHHS leaders realized
that rolling out a uniform statewide plan would be difficult. Instead, state and county leaders
crafted a unified vision and set of goals, and then gave counties the information and flexibility to
decide how best to achieve those goals. The WSS team developed communication and education
strategies that could encourage and make the case for change, while taking into account and
respecting the variation in counties.
The WSS team, which included both state and county representatives from the beginning,
knew that county involvement and buy-in was essential to the project’s success and that counties
varied in their commitment to the project. “We came into this with 30 to 40 percent of our
counties on board—another 30 to 40 percent excited but not necessarily believing it. Then the
naysayers,” said one WSS state-level team member.
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Work Support Strategies
Early on, the WSS team began a broad communication effort to inform all counties and
workers about the project in local, regional, and state-level meetings. The team members took
every opportunity to talk about WSS and their vision for service improvements, even during
meetings not specifically about the initiative. For example, team members made WSS a regular
topic during a long-standing monthly fiscal conference call between state staff and a majority of
counties to capitalize on the audience’s attention. Adding WSS to this call, in the words of one
county representative, is one part of “forcing communication of everyone on all fronts.” WSS
was also presented and discussed in local, regional, and state-level meetings with human services
workers, including at highlighted sessions of the annual Social Services Institute in fall 2011,
which were attended by more than 200 social services staff, and at quarterly stakeholder
meetings.
The WSS team also invited county leaders to attend and participate in WSS team meetings,
asking them to keep their staff in the loop as well. Those leaders began by asking staff for input
during agency meetings. “That went a long way in setting a foundation for the initiative,” one
county leader told us. The WSS team followed up with surveys to continue receiving staff
feedback. “Keeping them involved so that when this initiative comes full circle, staff will feel
they have a part in developing the final process—that’s always a plus,” the county leader said.
Site visits were a key strategy for educating and informing counties and bringing them on
board with the vision for integration. The WSS team held two-day visits initially in four counties
and then another 10 counties later in the year, conducting focus groups and surveys with clients
and workers to “understand the client experience and identify duplication of processes in
applying for, obtaining, and maintaining benefits” for SNAP, Medicaid, Work First, and child
care. The sites chosen to visit—a mix of counties from urban and rural areas—included counties
with high processing rates and others with low processing rates in order to observe different
business processes and challenges. The WSS team developed interview protocols to discuss the
project with staff and to hear their ideas and concerns around policy simplification, business
process change, and challenges in determining eligibility. As a side benefit, soliciting feedback
from staff engaged them in the project and made them feel as though change was happening with
them as opposed to happening to them.
Early Lessons From The Work Support Strategies Initiative: North Carolina
13
Clients were also interviewed about their experiences and needs. During the site visits, the
team mapped out the eligibility intake process in each county they visited, following a client
from the moment he or she entered the local office to the end of the eligibility interview. These
on-site exercises gave the team a three-dimensional look at the client’s experience and the
business processes at work in each county, and helped the team identify opportunities to increase
efficiency.
The WSS team needed to engage frontline workers as well, a challenge not limited to states
that operate their programs through counties. In talking about redefining customer service and
streamlining processes, some frontline staff feared losing their jobs or losing the human
connection they make with clients. One WSS leader told us that frontline staff did not disagree
with the project’s goals or vision, but were worried about automating tasks. This team member
added, “They know we need to be accountable and transparent and get people benefits…and
create efficiencies…. It bothers some of our workers to not provide that personal touch, but
we’re reframing it to say that it’s better customer service” to get families all the benefits for
which they’re eligible as quickly as possible. That framing seemed to resonate with county
workers, though many were still anxious about losing their jobs.
In the local, regional, and state-level meetings, the team talked frontline workers through the
WSS vision, explaining how, for example, walking a family through every step of the process is
slower and therefore not a sign of good customer service. One county director remarked on the
value of explaining to workers why an integrated approach is better and talking through what
that might look like, as opposed to simply prescribing business process change. When he showed
staff how many repeat customers they have because of the siloed programs, they saw the benefit
of integration from the customer’s perspective. “It is a no-brainer for them to get that point,” he
said. Having the workers actively participate in redefining good customer service and
strategizing a reengineered business process creates a partnership with the workers and invests
them in the process of change.
Also during the planning year, the state child care division and nine counties came together
with the core WSS child care technical assistance team to jointly think about how to simplify and
align child care policies using the WSS goals. This collaboration provided a forum to discuss the
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realities in the counties and revealed a range of challenges ahead. This meeting further cemented
the WSS vision and an understanding between counties and the state that they were working on
change together.
The state began to encourage counties to strategize innovative business process strategies
rather than waiting for the state to hand down orders. As mentioned earlier, the WSS team
encouraged counties to choose their own approaches, using the WSS vision as a guide. The WSS
state leaders saw the benefit of using counties as “test kitchens” for new approaches before
investing money prematurely in a statewide rollout. The state was clear that the point was not to
get every county to the same business model for benefit administration, but to get counties to
innovate with the goal of streamlined and improved service to clients.
Even with the state’s official encouragement, however, not all counties felt comfortable
taking the reins to develop and test strategies. The WSS team learned that some counties still
feared getting a quality-control penalty. The team had to build trust with the counties to enable
them to be “creative and consumer-centric, rather than all about the rules,” a state team member
said. The WSS team reiterated that message at a January 2012 leadership summit with county
leaders: “Don’t wait for us or for NC FAST. Here are the goals we’re looking to achieve…here
are examples from other states of ways they’ve tried and learned… go forth and do” and share
the lessons of your success.
Counties played a big role in educating each other about the WSS vision and process change.
Prior to WSS, motivated by growing caseloads and the implementation of health reform, the
NCACDSS had formed a workgroup to explore program and policy simplification. They came
up with a list of specific recommendations for how the state could reduce client and
administrative burden by simplifying programs, aligning eligibility, and improving technology.
After WSS began, the association formed a WSS committee by consolidating several of its other
committees, providing a forum for integrated program discussions. The association’s annual
leadership summit in January featured WSS and provided updates on its progress as well as
solicited county directors’ input.
Early Lessons From The Work Support Strategies Initiative: North Carolina
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Strong county leaders helped push the project forward and acted as trailblazers for their peers
in other counties. One WSS leader commented that some county staff are “more forwardlooking, the ones who understand and know what is going on and get on board and be part of it.”
Those early adopters and innovators encouraged other counties to test business process and
policy changes. These county directors offered up lessons and best practices from the business
process changes they had made in the past so that more hesitant counties could learn from their
successes and mistakes.
To spread business process improvements beyond the early adopter counties, the North
Carolina team developed a catalogue of innovative and effective business processes already
operating in some counties. A list of best practices highlights possibilities and achievements, and
can encourage counties that are more resistant to change for fear of wasting time, money, and
patience. The WSS project lead said it best: “It’s difficult for one county to sit here and not
change while your neighbors are changing. If one county can save costs and time, its neighbor
can’t just sit there and not change.” Further, encouraging change by highlighting existing
innovative practices is a great example of North Carolina’s WSS strategy for working with the
counties.
Finally, the WSS team also understood that to engage effectively with the counties, they
would have to break down state program silos. State staff had always communicated regularly
with county leaders, but the nature of the WSS project and its focus on streamlined and
integrated service delivery demanded a heightened level of collaboration among state agencies
and counties. In the past, “different programs were not really coming together to discuss
changes,” a county representative said. “It was as if [state] changes were in silos and would only
be made for specific programs.” The WSS team had to model the change they wanted to see in
the counties.
Using Data to Shape Policy, Process, and Technology Decisions
“[Data are] helping us evaluate all the ideas on the table….The data keep driving us back to
where we should be.”
—WSS team member
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The WSS national technical assistance team had suggested that WSS state teams study their data
on cross-enrollment in multiple benefits programs, why and when churning happens, timeliness
of case processing, program retention, and other key statistics. When the North Carolina team
first sat down to look at that data, they realized that what they had in their system couldn’t tell
them what they wanted to know. Reflecting later, a WSS leader told us that the data available for
management could be confusing to users. One example was a county manager who called the
state confused because the data showed that the number of applications his agency had processed
in the prior year was equal to “the entire population of the county, and that can’t be true.’” It
turned out that because families churn on and off benefits due to administrative difficulties in the
redetermination process, the system counted the same individuals as applicants over and over.
In the planning year, North Carolina faced technical problems accessing data as well as
problems using the data strategically. On the technical side, the team found that case identifiers
are different across programs, making it difficult to match a client’s SNAP file with his Medicaid
file to get a sense of cross-enrollment. The state’s data warehouse is organized as crosssectional—not longitudinal—views, which makes it hard to look at individuals over time. State
and county data is pulled programmatically, presenting another challenge to looking at crossenrollment. Getting a complete picture of working families receiving assistance was not easy.
As in many of the WSS states, North Carolina had trouble identifying the important
questions to ask and using the available data to answer them. Often the people asking the
questions were not the ones with direct knowledge of the available data. The key, according to
one WSS team member, was first discerning what they needed to know to make important
decisions and then figuring out which data would give them that information.
To address these challenges, the WSS team developed a work plan to collect the missing data
they felt would inform the direction they should take and provide the justification for making
changes. The WSS team compiled a list of every desired data point, the reason for collecting
each point, its priority level, method of collection, and the person in charge of obtaining the data.
In a handful of counties, data was collected through site visits. DHHS called on a longtime data
partner at the University of North Carolina at Chapel Hill (UNC-Chapel Hill) to do some of the
heavy lifting of the data analysis. Interestingly, this university partner had once been a frontline
Early Lessons From The Work Support Strategies Initiative: North Carolina
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county worker, and he noted the importance of partnering with someone possessing both the
strength of methodological training and the understanding of how programs operate.
In addition to confirming issues that needed to be addressed, such as duplicative program
processes, the data gathered during the planning year steered the WSS team in new directions
and helped them avoid costly mistakes. For example, the state initially planned to develop a call
center because data showed that local offices were being flooded with calls. However, after
taking a broader view of the reasons behind the calls, the WSS team learned that most calls to
local offices were about application delays and processing problems for clients. “If we could go
to same-day processing, we may not need call centers,” one WSS staff member told us. The team
concluded that streamlining processing was the answer, not call centers. Eliminating the need for
the calls was a better long-term solution for both staff and clients.
Finally, learning from these data efforts led the WSS team to formulate a plan for data-driven
decisionmaking. The counties will always have flexibility in developing processes and
operations, but benchmarks for outcomes will be the ultimate measure of success. The state
needs to develop these measures—a “data dashboard”—and produce them for each county.
Having these benchmarks will promote accountability within county flexibility and move the
system toward data-driven changes.
Using the Planning Year to Build Momentum and a Culture of Learning
“[Reform efforts] without outside help or facilitation or leadership have not produced
lasting results. . . . That was a theme that kept coming up, and we needed WSS to
reinvigorate and align all these efforts. Having someone to organize and orchestrate and
document everything is an undervalued product.”
—WSS team member
“[A key insight from peer site visits was] the continuous improvement rhythm that
successful states are able to get in, where they’re able to consistently try new things and test
them.”
—WSS team member
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North Carolina’s WSS team made use of the planning year as a springboard for accomplishing
its goals. The team members took time to identify what they wanted to accomplish, how and
when they would achieve each goal, and who needed to be involved. Armed with this list of
goals and objectives, the team then drew up a timeline and assigned a leader for each activity.
This approach yielded increased transparency and accountability for the team, both a short- and
long-term perspective on all the team hoped to accomplish in the planning year, a clearly
articulated path toward developing an implementation plan, and an understanding of how each
piece contributes to the whole. This high-level plan with staff assignments and deadlines served
as a roadmap to guide the team’s work in the planning year.
That roadmap, however, was flexible enough to allow for some useful detours. The team
realized over the course of the year that, as one team member put it, “[the plan] was iterative. As
we learned one thing, we realized we wanted to talk about something else. We didn’t follow the
plan perfectly, but it did give us a good structure and we checked ourselves against it.”
WSS team members stayed in frequent communication with each other throughout the
planning year. The biweekly team conference calls gave the team time to discuss ideas, solve
problems, and coordinate activities. This regular communication kept the project on track and
created a feedback loop on the various activities being carried out.
Part of the planning year was spent developing a marketing strategy to communicate the new
vision for human services in North Carolina and the efforts undertaken by WSS and other
initiatives to realize that vision. “I can’t understate the messaging piece of this,” a key WSS team
member told us. “It’s so important to invest time in figuring out what you’ll say and to whom.”
By the end of the planning year, a WSS marketing team was formed to coordinate all outreach
and marketing efforts geared toward different audiences.
While the WSS team had made great progress, they were concerned that the project would
not achieve its full potential if staff were forced to compete with other priorities. They also
thought that earlier efforts to create change had been hindered by not having staff solely
dedicated to managing those efforts. This is particularly problematic when initiating systemic
change, because one step can lead to five. As one team member told us, “Every time we tried to
Early Lessons From The Work Support Strategies Initiative: North Carolina
19
do something we thought was small, it grew, and our reaction was to pull back because we didn’t
have the capacity.”
North Carolina needed staff explicitly charged with organizing meetings, documenting
decisions, and driving change for WSS alone. Their solution was to bring in a trusted outside
partner to help manage the process. The Public Consulting Group (PCG) played an important
role over the course of the planning year. They were already working with the state on the
Integrated Eligibility Project and other streamlining efforts, so they knew the players and state
context from the start. The state team used the planning grant resources to bring in PCG to take
over most project management tasks, which state staff struggled to do alongside their other
commitments. Every state WSS team member agreed that bringing in a contractor was critical.
PCG kept track of ideas, deliverables, and deadlines; facilitated meetings; wrote progress reports;
conducted site visits to counties; helped design policy changes and pilots; reached out to
stakeholders; and ensured that everyone was informed and on board with the plan. State team
members were still heavily involved in those activities, but PCG kept the ball rolling.
Participants reported that PCG was able to maintain the momentum of the project in part
because they remained outside the maelstrom of state government. The exigencies of state
government programs affect the amount of time, energy, and resources that state and county staff
can give to a project. PCG could pick up slack, if need be, when unforeseen situations occurred
(for example, when tornadoes swept through the state in early 2011) and could coordinate the
activities and players to keep the project moving forward. In addition, they were successful
because WSS leadership knew how best to use PCG resources, with a plan from the beginning of
the year.
PCG was not the only external consultant called upon during the planning year; the
Organizational Effectiveness group at the American Public Human Services Association
(APHSA) worked with WSS team members to develop their implementation plan. By the end of
the year, PCG felt that its close involvement with WSS hindered its ability to serve as an
objective facilitator for developing the implementation plan. An APHSA representative visited
the WSS team in North Carolina to look at the data and lessons learned from the planning year
and to plan the course forward over the next several years.
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Work Support Strategies
The WSS team based their planning year efforts on the goals and vision laid out from the
project’s start, but they also made quick and visible changes early on to build support and
momentum. North Carolina’s WSS team was encouraged to use this model after visiting other
states that had been successful in reengineering their human services—an invitation extended to
each of the WSS states. The team hoped to instill the same flexibility and energy into WSS.
When talking with county directors, the WSS team emphasized the importance of trying out new
North Carolina Planning-Year Activities
Formed WSS team with state and county members and hired Public Consulting Group to carry out management
activities.
Held quarterly stakeholder meetings with state and county representatives, community groups, advocacy groups,
and academics.
Completed WSS data diagnostic tool—generating results on unduplicated program enrollment, program caseload
overlap, and procedural denials.
Carried out two-day site visits to four counties which included mapping intake business processes, conducting
interviews and focus groups with all levels of staff, and reviewing county case file system and eligibility tools; Later
in year conducted additional site visits and phone calls with 10 more counties to catalogue best practices related
to work support programs.
Conducted client interviews to identify areas of difficulty or confusion for clients.
Implementation of using FNS (SNAP) income-eligibility requirements for Subsidized Child Care (begun prior to
WSS).
Continued policy review (started prior to WSS) across programs of the potential for simplification, including
income and resource requirements, verification documents, and joint policy manuals.
WSS team member participation in NC FAST benefit system development.
WSS team member participation in health reform preparation meetings.
WSS carried out a pilot in two counties on aligning certification periods between FNS and Medicaid.
In line with WSS’ mission, North Carolina was selected to be part of the U.S. Department of Agriculture’s
demonstration evaluation for eliminating the SNAP face-to-face interview.
Senior DHHS staff and WSS team members attended and presented on WSS at regional NCACDSS meetings and
their annual Social Services Institute meeting (professional development for more than 200 county social services
staff). Also, WSS team presented at their leadership summit, soliciting input on next phase of WSS.
WSS team members went on site visits to New Mexico, Idaho, and Washington state through the WSS project to
learn about effective eligibility systems in other states.
Established a Policy Governance Board to direct unified policy development across DHHS economic eligibility
programs.
Partnered with American Public Human Services Association to carry out a series of action-planning sessions to
develop next steps for WSS after planning year.
Early Lessons From The Work Support Strategies Initiative: North Carolina
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ideas early on and carrying out these quick wins “so people can see something tangible coming
out of the effort.”
Promising change and then taking years to follow through can sink support and enthusiasm
for any project. Building in flexibility to create visible, successful changes along the way can not
only maintain the momentum of a project but also help it pick up speed and support. Many
participants felt that North Carolina’s planning-year activities exemplified this strategy to build
in wins and change the culture at the same time.
Conclusions
North Carolina’s WSS planning year allowed the state to create a framework for integrating and
streamlining work support programs. The state’s overarching goals—to increase the share of
eligible families receiving and maintaining work support benefits while reducing administrative
and client burden—did not change over the planning year. But over this period, North Carolina
was able to consolidate its vision and mission at the state level, breaking down program silos and
communicating that vision clearly to counties, state leadership, and other stakeholders. The
ongoing efforts to implement NC FAST, the new benefits eligibility IT system, and planning for
implementation of health reform were used as opportunities to further the WSS vision. Specific
work in the counties to review business processes and encourage county innovation cemented the
state–county partnership moving forward. Work reviewing potential areas for policy change and
testing changes, such as aligning certification dates, was complemented by development of the
Economic Benefits Policy Governance Board structure for assuring cross-program input to new
changes. Finally, the work of the planning year was informed by collection and analysis of data
and exploration of how to improve state capacity in this area.
Toward the end of the year, North Carolina began actively planning for the next phase of the
WSS project and was subsequently awarded a three-year WSS implementation grant. North
Carolina’s action plan for implementation spells out a detailed set of steps for moving forward to
build on planning-year activities. The plan includes a structured plan for working with counties
to assist them in reconfiguring their services and organizational structures to meet state outcome
expectations while allowing for county innovation and variation. It also includes a set of
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anticipated outcomes with specific measures to mark progress toward these goals. The state plans
to increase data collection and analysis capacity to measure these outcomes and continue
movement toward data-based decision making while also investing in staff development. WSS
team members voiced the opinion that the planning year allowed North Carolina to lay the
groundwork and begin the work toward lasting change.
Early Lessons From The Work Support Strategies Initiative: North Carolina
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References
Bureau of Labor Statistics. 2012. “Unemployment Rates for States Monthly Rankings Seasonally
Adjusted.” Washington, DC: US Department of Labor.
Cunnyngham, Karen. 2012. State Supplemental Nutrition Assistance Program Participation Rates in
2010. Washington, DC: Food and Nutrition Service, USDA.
http://www.fns.usda.gov/ora/menu/Published/snap/FILES/Participation/Reaching2010.pdf.
Kaiser Family Foundation. 2013. “State Health Facts.org: Medicaid & CHIP.”
http://www.statehealthfacts.org/comparecat.jsp?cat=4&rgn=6&rgn=1.
Kenney, Genevieve, Victoria Lynch, Michael Huntress, Jennifer Haley, and Nathaniel Anderson. 2012.
“Medicaid/CHIP Participation Among Children and Parents.” Timely Analysis of Health Policy
Issues. Robert Wood Johnson Foundation. http://www.urban.org/UploadedPDF/412719-MedicaidCHIP-Participation-Among-Children-and-Parents.pdf.
U.S. Census Bureau. 2013. “Percent of Individuals for Whom Poverty Status Is Determined Below 200
Percent of Poverty in 2011. From the American Community Survey – 1-Year Estimates.”
Washington, DC: US Department of Commerce.
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Methodological Note
This report is based on several sources, including evaluation team members’ on-site and
telephone interviews with state and county North Carolina WSS team members and others in the
state working on WSS and related efforts; WSS materials, including quarterly progress reports
and quarterly call notes; and state documents, including the WSS proposal, action plan,
presentations, relevant web sites, WSS data exercise results, evaluation documents, and other
materials. During a three-day visit to North Carolina in spring 2012, the evaluation team held 11
interviews (supplemented with several phone interviews) with the WSS management team, NC
FAST staff, data staff and the university partner, the Association of County Commissioners, a
governor’s office representative, an advocacy organization, representatives from four county
departments of social services, and state agency leadership and staff from SNAP, child care,
Medicaid, and other economic assistance programs.
The goal of this Phase I evaluation was to draw on these sources to document North Carolina’s
activities during the WSS planning year, including the challenges the state encountered and the
approaches chosen to overcome them. This goal arose from the particular features of the
planning year and the nature of the lessons that could be distilled. During this phase, states were
assessing their current strengths and weaknesses, and designing and testing potential next steps,
culminating in the development of an action plan (with clear goals and measurable targets for
reaching them). From an evaluation perspective, therefore, it was too early to assess whether
states had met measurable goals, but not too early to document what actually did happen, what
bumps occurred along the way, and how states responded. Thus, during the on-site visits, the
evaluation team members attempted to gather input from varied perspectives, including local
office staff and community stakeholders, but did not attempt to comprehensively gather input
from all perspectives in order to evaluate the effectiveness of planning-year activities.
Six states (Colorado, Idaho, Illinois, North Carolina, Rhode Island, and South Carolina) are
continuing on to Phase II of the evaluation. This next stage has three major goals: to document,
understand, and draw lessons from the implementation of WSS activities in the states; to identify
and track over time key outcomes that the state would expect to be affected by its activities and
interventions; and to measure the effect WSS or specific activities under WSS had on key
outcomes. To meet these goals, the Phase II evaluation will include implementation analyses and
data tracking for all six states, and impact analyses to provide quantitative causal results where
feasible. Each state’s evaluation will be tailored to its particular activities, goals, priorities, and
data availability. The overall evaluation will combine information, analyzing data and results
from across all six states.
Early Lessons From The Work Support Strategies Initiative: North Carolina
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